NCLEX 风格的优先排序与委派：速成包

公式表、每个专题的关键方法步骤和 14 道练习题，完整解答附在最后。

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1公式与方法

优先排序与委派

方法

  1. 问自己：如果什么都不做，什么会最快伤害患者。
  2. 应用 ABC（心脏骤停时为 C-A-B），然后是 Maslow 需求层次：生理需要先于安全，安全先于心理需要。
  3. 比较各选项：急性先于慢性，不稳定先于稳定，意外先于预期，全身性先于局部，并将每项发现与患者的基线对照。
  4. 除非是紧急情况，否则先评估再行动；然后选择其他步骤所依赖的那一步。
  5. 委派时核对五项正确：任务、情境、人员、指示和监督。评估、宣教和评价仍由注册护士负责。

感染控制与患者安全

方法

  1. 对每位患者都从标准预防开始：手卫生、针对预期暴露的个人防护装备、安全使用锐器。
  2. 按传播途径追加预防措施：接触传播（隔离衣、手套）、飞沫传播（外科口罩）、空气传播（N95、负压病房）。
  3. 保持无菌物品的无菌状态：如有疑问就视为不无菌；更换，绝不擦拭。
  4. 预防环境中的伤害：防跌倒措施，约束仅作为最后手段，火灾时用 RACE 和 PASS。
  5. 核对给药的正确原则、两个身份识别信息，以及对高警示药物的额外保障；报告差错和险兆事件。

实验室检查值与电解质

方法

  1. 把数值与本实验室自己的参考范围比较，再与患者的基线和趋势比较。
  2. 检查标本：溶血、延迟，或在静脉输液附近采血都可能得出错误结果。
  3. 把数值与其典型体征以及引起它的药物和疾病联系起来。
  4. 注意相互作用：低钾或低镁会增加地高辛中毒的风险；脱水会使锂浓度升高。
  5. 对患者采取行动：评估，血药浓度不安全时暂停用药，复述危急值并通知开医嘱的医生。

内外科护理：心血管与呼吸

方法

  1. 说出问题所在：泵衰竭、动脉阻塞、节律、血栓、气道狭窄、感染或设备问题。
  2. 先检查危险征象：低氧、低血压、胸痛、新出现的意识模糊、冰冷无脉搏的肢体。
  3. 让氧疗与患者相匹配：大多数人为 94–98%，有 CO₂ 潴留风险者为 88–92%。
  4. 把每种药物与其检测和风险联系起来：华法林与 INR，肝素与 aPTT 和血小板，利尿剂与血钾。
  5. 选择安全的第一步措施，然后升级处理并重新评估。

内外科护理：神经、内分泌与肾脏

方法

  1. 对每位新出现意识模糊、乏力或癫痫发作的患者都检查血糖。
  2. 把意识水平作为脑部问题最早的警示；瞳孔变化和库欣三联征出现得较晚。
  3. 对于糖尿病急症，要区分 DKA（酮体、酸中毒）和 HHS（渗透压很高、脱水）；先补液。
  4. 对于钠和水，要判断是 ADH 过多（SIADH）还是缺乏（尿崩症），并缓慢纠正慢性变化。
  5. 对于肾脏问题，把原因分为肾前性、肾性或肾后性，并监测血钾和液体。

内外科护理：消化、围手术期与肿瘤

方法

  1. 想一想可能隐藏着什么：内出血、无发热的感染、SpO₂ 正常背后的通气不足。
  2. 利用术后的时间来缩小并发症的范围：出血在数小时内，胸部问题在数天内，伤口和吻合口漏出现得更晚。
  3. 对于疼痛，要评估、用多模式镇痛治疗、重新评估，并且在每次使用阿片类药物时监测镇静程度。
  4. 对于癌症患者，把低谷期的任何疾病都当作中性粒细胞减少性脓毒症处理，并了解肿瘤急症。
  5. 对于烧伤，只计算浅二度/深二度和三度的面积，从烧伤的时刻开始计算 Parkland 时间，并根据尿量调整。

2练习题

1.优先排序与委派中等

A patient on a nasal cannula at 6 L/min still has a low SpO₂. What should the nurse do?

  1. ARemove the oxygen to see if the SpO₂ changes
  2. BRecheck the SpO₂ at the next routine set of observations in four hours
  3. CTurn the nasal cannula up to 15 L/min
  4. DReport it, because a different oxygen device is likely to be needed
2.优先排序与委派困难

A patient arrives at the emergency department with a plan to end their life, but has normal vital signs. Which ESI level fits best?

  1. ALevel 5
  2. BLevel 2
  3. CLevel 1
  4. DLevel 4
3.感染控制与患者安全中等

Which nursing care reduces the risk of ventilator-associated pneumonia?

  1. ALeaving secretions in the mouth to protect the airway
  2. BRegular oral care to reduce bacteria in the mouth
  3. CChanging the ventilator circuit every few hours
  4. DLying the patient flat for most of the day
4.感染控制与患者安全困难

一名护士正准备给予静脉吗啡。患者的呼吸频率为 9 次/分，非常嗜睡。护士应怎么做？

  1. A给药，因为之前主诉过疼痛
  2. B暂停给药，评估患者并通知开医嘱者
  3. C给半量
  4. D给药，明天再复查呼吸频率
5.实验室检查值与电解质中等

A patient had a right mastectomy with removal of axillary lymph nodes. Where is the best place to draw blood?

  1. AThe right hand
  2. BThe right arm
  3. CThe left arm
  4. DEither arm equally
6.实验室检查值与电解质困难

A patient taking an SGLT2 inhibitor has nausea and fast breathing. Glucose 190 mg/dL (10.5 mmol/L), pH 7.15, bicarbonate 10 mEq/L, blood ketones high. What is the most likely diagnosis?

  1. AEuglycemic diabetic ketoacidosis
  2. BHyperosmolar hyperglycemic state
  3. CSimple fasting ketosis only
  4. DRespiratory acidosis from COPD
7.临床护理中等

When a patient returns to the ward from theatre, what should the nurse assess first?

  1. AAirway, breathing, circulation and level of consciousness
  2. BThe discharge date
  3. CThe patient's dietary preferences for the next meal
  4. DWhether visitors are waiting to see the patient
8.临床护理困难

A patient with severe ulcerative colitis develops abdominal distension, fever and tachycardia, and the number of stools falls. What complication should be suspected?

  1. ACoeliac disease
  2. BConstipation from dehydration
  3. CToxic megacolon
  4. DRecovery from the colitis
9.内外科护理：心血管与呼吸中等

Why is intravenous furosemide given slowly rather than as a rapid push of a large dose?

  1. ARapid doses cause the potassium level to rise
  2. BRapid high doses can damage hearing
  3. CSlow injection makes the urine output larger
  4. DRapid doses cause severe constipation
10.内外科护理：心血管与呼吸困难

Two days after coronary artery bypass surgery, a patient feels palpitations. The pulse is irregularly irregular at 140/min and BP is 112/70 mmHg. Which rhythm is most likely?

  1. AComplete heart block
  2. BVentricular fibrillation
  3. CSinus tachycardia
  4. DAtrial fibrillation
11.内外科护理：神经、内分泌与肾脏中等

A patient on peritoneal dialysis has gained weight and has higher glucose levels. Which part of the treatment is the likely cause?

  1. AProtein lost into the dialysis fluid
  2. BSodium lost into the dialysis fluid
  3. CGlucose absorbed from the dialysis fluid
  4. DAir entering the abdomen during exchanges
12.内外科护理：神经、内分泌与肾脏困难

A large pituitary tumour presses on the optic chiasm. Which visual field defect is most typical?

  1. ALoss of the outer half of the field in both eyes
  2. BLoss of central vision in both eyes
  3. CComplete blindness in one eye only
  4. DLoss of the inner half of the field in both eyes
13.内外科护理：消化、围手术期与肿瘤中等

Which is correct when caring for a patient with a PICC line?

  1. AUse the PICC arm for heavy lifting to keep it flexible
  2. BAvoid taking blood pressure on the arm with the line
  3. CLeave the external length unchecked once it is placed
  4. DFlush the line only when it blocks
14.内外科护理：消化、围手术期与肿瘤困难

On day 3 after laparoscopic cholecystectomy, a patient has abdominal pain, fever and mild jaundice, and green fluid is draining from the drain. What is most likely?

  1. AUrinary retention
  2. BNormal post-operative drainage
  3. CA bile leak
  4. DA wound haematoma

3溶液

1.优先排序与委派

答案: D · Report it, because a different oxygen device is likely to be needed

为什么是这个答案

Standard nasal cannulas are usually run at up to about 6 L/min; higher flows dry the nose without much benefit. If the patient still needs more oxygen, the nurse assesses and escalates for a different device.

答案

D · Report it, because a different oxygen device is likely to be needed
2.优先排序与委派

答案: B · Level 2

为什么是这个答案

Active suicidal ideation with a plan is a high-risk situation, so the patient is ESI level 2. They need prompt evaluation and a safe environment with close observation.

答案

B · Level 2
3.感染控制与患者安全

答案: B · Regular oral care to reduce bacteria in the mouth

为什么是这个答案

Oral care, including tooth brushing, reduces the bacteria that can be aspirated around the endotracheal tube. It is part of ventilator care along with head elevation and sedation review.

答案

B · Regular oral care to reduce bacteria in the mouth
4.感染控制与患者安全

答案: B · 暂停给药，评估患者并通知开医嘱者

为什么是这个答案

呼吸减慢和镇静提示阿片类药物过量，再给一剂可能导致呼吸停止。护士应暂停给药，刺激并评估患者，按医嘱准备纳洛酮并上报升级。

答案

B · 暂停给药，评估患者并通知开医嘱者
5.实验室检查值与电解质

答案: C · The left arm

为什么是这个答案

After axillary node removal, venipuncture and blood pressure readings are usually avoided on that side to reduce the risk of lymphedema and infection. The opposite arm is used whenever possible, according to policy.

答案

C · The left arm
6.实验室检查值与电解质

答案: A · Euglycemic diabetic ketoacidosis

为什么是这个答案

SGLT2 inhibitors can cause DKA with only mildly raised glucose because glucose is lost in the urine. Ketones and acidosis must be checked in any unwell patient on these drugs, even with a near-normal glucose.核对依据: Ketones blood test · MedlinePlus (NIH) (2025)

答案

A · Euglycemic diabetic ketoacidosis
7.临床护理

答案: A · Airway, breathing, circulation and level of consciousness

为什么是这个答案

Early postoperative assessment checks the airway, breathing, oxygen saturation, circulation, consciousness, pain, wound and drains. This detects anaesthetic and surgical complications early.

答案

A · Airway, breathing, circulation and level of consciousness
8.临床护理

答案: C · Toxic megacolon

为什么是这个答案

Toxic megacolon is acute dilatation of the inflamed colon with systemic toxicity, and it can perforate. Reduced stool frequency with worsening distension is a warning sign needing urgent surgical review.

答案

C · Toxic megacolon
9.内外科护理：心血管与呼吸

答案: B · Rapid high doses can damage hearing

为什么是这个答案

High plasma levels of loop diuretics can cause tinnitus and hearing loss (ototoxicity), especially with fast injection, renal impairment or other ototoxic drugs such as aminoglycosides. Large IV doses are therefore given slowly.

答案

B · Rapid high doses can damage hearing
10.内外科护理：心血管与呼吸

答案: D · Atrial fibrillation

为什么是这个答案

New atrial fibrillation affects a large proportion of patients in the first days after cardiac surgery, often due to inflammation, electrolyte shifts and stress. Management includes a 12-lead ECG, checking potassium and magnesium, rate or rhythm control and considering anticoagulation.

答案

D · Atrial fibrillation
11.内外科护理：神经、内分泌与肾脏

答案: C · Glucose absorbed from the dialysis fluid

为什么是这个答案

Standard PD fluids contain glucose to pull water out by osmosis. Some glucose is absorbed, adding calories and raising blood glucose. Glucose monitoring and diet advice are needed, and other solutions may be used.

答案

C · Glucose absorbed from the dialysis fluid
12.内外科护理：神经、内分泌与肾脏

答案: A · Loss of the outer half of the field in both eyes

为什么是这个答案

The chiasm carries crossing fibres from the nasal retinas, which see the temporal (outer) fields. Compression causes a bitemporal hemianopia. Patients may bump into objects at their sides.

答案

A · Loss of the outer half of the field in both eyes
13.内外科护理：消化、围手术期与肿瘤

答案: B · Avoid taking blood pressure on the arm with the line

为什么是这个答案

BP cuffs and tourniquets on the PICC arm can damage the line. The external length and site are checked, the dressing is kept intact, and the line is flushed and used with aseptic technique according to policy.

答案

B · Avoid taking blood pressure on the arm with the line
14.内外科护理：消化、围手术期与肿瘤

答案: C · A bile leak

为什么是这个答案

Bile leakage from the cystic duct or a duct injury causes pain, fever and sometimes jaundice, with bile in the drain. It needs urgent surgical review and often ERCP and stenting.

答案

C · A bile leak

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